COPD and antibiotics.

Welcome back to POTD. 

The weekend has come and the weekend has gone. I know you've all been holding your breath to hear about----

A message from our sponsors:

Take a deep inhale. feel some wellness. feel the firmness of your feet on the floor. hold onto your seat.   

Exhale nice and slowly......like someone with a COPD exacerbation.

Because today we're discussing antibiotic coverage in acute COPD Exacerbations. I know you've been waiting a lung time for this one. 

Background

  • Acute COPD exacerbations (AECOPD) account for ~1.5 million ED visits annually in the ED.

  • Many physicians routinely prescribe antibiotic coverage for AECOPD

  • a 2018 review demonstrated antibiotic prescriptions given on 39% of ED visits for AECOPD between 2009-2014.

  • Due to the structural changes in the bronchi of COPD patients they are more prone to bacterial colonization (as opposed to asthmatics - which have no structural change but a reactive process)

Do guidelines exist?

  • Sure do. 

  • if the patient appears infectious (think fever) administer antibiotics. This is understandable given their risk factors and bronchial structural changes.

  • Several guidelines exist for more subtle cases, they exist as follows: (see chart below)

    • Global initiative for Chronic Obstructive Lung Disease:

      • Antibiotics should be given to

        • patients with all 3 of the following cardinal symptom

          1. increased dyspnea

          2. increased sputum volume

          3. increased sputum purulence

        • patients with 2 cardinal symptoms, if there is increased purulence

        • patients requiring noninvasive or invasive ventilation

    • American Thoracic Society/European Respiratory Society

      • hospitalized patients with chanegs in sputum characteristics

      • all patients admitted to an ICU

    • Canadian Thoracic Society

      • patients with severe purulent AECOPD

    • National Institute for Health and Clinical Excellence

      • patients with more purulent sputum

  • Basically, pay attention to that sputum. take a thorough history and discuss changes in sputum production. 

-Elly

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A common missed ED diagnosis

Q for all of You.

If i were to tell you that there is a disease entity that has-

  • an estimated prevalence of 2% in the US 

  • significant morbidity

  • is easily treatable

  • and that many of us have likely missed it in the ED

Would you know what it is?

Well. You're about to.

Wernicke Encepahalopathy. 

What is it?

  • An encephalopathy that occurs secondary to thiamine (B1) deficiency

It's a disease only seen in alcoholics, right?

  • ehhh, not quite.

  • Wernicke most commonly is found in alcoholics (an estimated 12.5% of them), but has also been found in people who have bariatric surgery, hyperemesis gravidarum, and AIDS (one study found evidence of wernicke in 10% of autopsies in AIDS patients)

Well how does it present.

  • Classically has a triad of ataxia ophthalmoplegia, and AMS

  • though the full triad is only seen in <10% of patients

Is there a diagnostic tool available?

  • Sure is, diagnosis is made with 2/4 of the following criteria

    • Dietary deficiencies

    • Oculomotor deficiencies

    • Cerebellar Dysfunction (ataxia)

    • AMS/mild memory impairment

Why is it important that I treat it?

  • An estimated 60% of patients will have residual defecits

How do I treat it

  • pretty simple.

  • THIAMINE. 

  • 500mg IV thiamine three times a day for 3 days, followed by 250mg IV for 2-3 days

    • there is conflicting evidence about the amount of thiamine to give. Yet all agree that thiamine is relatively harmless- basically just give a lot of thiamine

    • IV administration is important here. chronically malnourished patients (especially those with ethanol usage) do not absorb thiamine well in the GI tract.

    • co-administer magnesium IV - hypomagnesemia promotes thiamine resistance

  • the 100mg we give in our bannana bags is preventative, and can provide sufficient thiamine for 1 week

So you're saying every confused alcoholic that's stumbling in the ED requires hospital admission for IV thiamine? That'll do great for our boarding issues in the ED

  • Not quite.

  • But if your drink patient is clinically sober and is then witnessed to have a wide based gait on their way out the ED. take a minute. have a conversation. do a brief ocular neuro exam. look for weird eyeball movements. 

  • often times patients will have rapid improvement from an IV thiamine dose (within 30 minutes). While not specific, if this happens the patient should definitely be admitted for IV thiamine. 

How about that thiamine before glucose thing. Do i need to withhold glucose from a hypoglycemic alcoholic.

  • Meh. NO!

  • in theory, a glucose load increases thiamine requirements. The though was that giving a dextrose load can push the at risk patient into Wernicke. But studies have not shown this to be the case. 

  • give your hypoglycemic patient glucose. just do it. Swoosh style. 

What's the pathophysiology behind it?

  • Never thought you'd ask!

  • Every ED docs favorite cycle - the Krebs cycle

  • Thiamine is a co-factor for pyruvate dehydrogenase, which converts pyruvate --> Acetyl-CoA, which then enters the Krebs cycle and results in ATP production

  • So no thiamine = no ATP

  • no ATP = bad. 

That's all.

-Elly

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POTD. Pediatric Grand Round. Pediatric Fevers

Today’s Pediatric grand rounds was given by Dr. Prashant Mahajan, MH, MPH, MBA. 

  • Professor and Vice-chair of the department of Emergency Medicine; Professor of Pediatric Medicine, Division Chief of Pediatric Emergency Medicine, Professor of Pediatrics at the University of Michigan

  • For those that don’t know him- He’s really smart and has done a ton of research on febrile infants

  • and he's proposing a new model to rule out serious bacterial infections in infants <60 days old. 

TL:DR

  • Serious Bacterial Infection (SBI) can be ruled out febrile infants from 29-60 days old with a-

    • Negative UA

    • Absolute Neutrophil Count (ANC) < 4090/μg

    • Procalcitonin < 1.72 ng/m

  • This prediction rule has a

    • Sensitivity of 97.7% (95% CI, 91.3-99.6)

    • Negative predictive value of 99.6% (95% CI, 98.4-99.9)

    • Negative likelihood ratio of 0.04 (95% CI, 0.01-0.15)

    • Specificity of 60.0% (95% CI, 56.6-63.3)

  • This rule requires further validation, but has promise to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger.

The longer and more detailed approach:

- 8-13% of infants <60 days with  fever have a SBI

  • ~5-8% have a UTI

  • ~1-2% have bacteremia

  • ~0.5% have meningitis

- ~500,000 febrile infants are evaluated by healthcare professionals annually

  • Missed SBIs may lead to serious complications

  • Febrile infants frequently receive invasive management including lumbar punctures, broad spectrum antibiotics, and hospitalization

  • Variation exists in the management of febrile infants <60 days

  • 90% of those 28 days or less receive lumbar puncture and admission

  • The incidence of SBIs has decreased over time

  • We need to balance hospital related complications, costs, and increases in antimicrobial resistance with the consequences of missed SBIs

- Our screening tests to assess for SBIs have holes in them

  • Physical Exam

    • Yale Observation Scores (YOS) in infants with SBI’s have similar median scores to those without SBI’s

    • I didn't know the YOS was a thing either. It's a clinical score developed on 6 behavioral domains to predict SBI’s, 

  • CBC’s are not sensitive in ruling out bacteremia or meningitis

    • WBC< 5,000 has a sensitivity of 10%, specificity of 91%

    • WBC> 15,000 has a sensitivity of 18%, specificity of 87%

  • Several of the commonly used rules for febrile infants (Philadelphia, Rochester, Boston, and Pittsburgh) were not statistically derived and therefore lacked optimal balance between test sensitivity (avoiding missed SBIs) and specificity (preventing overtesting and overtreating patients without SBIs). Additionally, several included data from LP’s an invasive procedure not required in the newly proposed rule (Boston, Phladelphia, Pittsburgh, Milwaukee.

- In this study

  • Negative UA alone ruled out an SBI in 97.6% of cases

    • Anyone hear of diapedesis? Consult Hector Vazquez for more info

  • Negative UA + ANC <4090 ruled out SBI in 99.2% of cases

  • Negative UA + ANC <4090 + PCT <1.71 ruled out SBI in 99.8% of cases

- Further validation in a cohort with more SBI’s is needed before implementation of this new rule.

The conclusion

  • Dr. Mahajan recommends using this rule in infants 29-60 days old. He currently recommends pursing your institutions’s standard of care (Full Sepsis Workup) in infants 28 days old or less  

The Article:

https://jamanetwork.com/journals/jamapediatrics/fullarticle/2725042

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